A 40-years-male with mitral stenosis, mitral regurgitation, aortic stenosis and aortic regurgitation was undergoing mitral and aortic valve replacement. During routine intraoperative transoesophageal echocardiography (TOE), it was observed that there were two heads of postero­medial papillary muscle (PPM) and a chordae tendineae originating from one of them was inserting into the anterior mitral leaflet (AML, [Figure 1] and [Figure 2]).

Usually the antero-lateral papillary muscle consists of a single large trunk, whereas the PPM can have one to three heads.[1] From each papillary muscle head chordae tendinae originate and insert into the corresponding half of the mitral leaflet.[2] However few reports have described that chordate from PPM can insert into AML. Lam et al[3] examined the autopsy specimens of 50 normal hearts and reported that chordae in 2 hearts originated from PPM and inserted into the AML. Rusted et al have also pointed out that the chordae originating from PPM can insert into the apex of AML with an average length of 2.2 cm in men and 1.8 cm in women. The present patient also shows two heads of PPM and chordae from one of them inserting into AML. Since the two heads of the PPM were not visible in the conventional TOE views (e.g. transgastric midpapillary view at 0o ), modified proximal transgastric views have been shown.